Automating Racism: Is Use of the Vaginal Birth After Cesarean Calculator Associated with Inequity in Perinatal Service Delivery?
Bibliographic record
Abstract
OBJECTIVE: The clinical application of race-adjusted algorithms may perpetuate health inequities. We assessed the impact of the vaginal birth after cesarean (VBAC) calculator, which was revised in 2021 to address concerns about equity. The original algorithm factored race and ethnicity and gave lower VBAC probabilities to Black and Hispanic patients. METHODS: From 2019 to 2020, we conducted a multi-site, ethnographic study consisting of interviews and audio recordings of 14 prenatal visits. We used grounded theory to describe the social processes of racialization. FINDINGS: Across 4 sites, 12 obstetricians, 5 midwives, and 31 pregnant/postpartum patients participated. Seventy-four percent (N = 23) of the pregnant/postpartum individuals identified as racially minoritized, and the remaining 24% (N = 8) identified as White. We identified four processes that facilitated the "automation" of racism: adhering to strict cutoffs; the routine adoption of calculators; obfuscating the calculator; and the reflexive categorization of race and ethnicity. When clinicians adhered to strict cutoffs, they steered low-scoring Black and Hispanic patients toward repeat cesareans. If clinicians obfuscated the calculator, Black and Hispanic patients had to work to decode the role of race and ethnicity in their probabilities in order to pursue a VBAC. By reflexively categorizing race and ethnicity, the use of the calculator forced patients to choose a singular identity, even if it obscured the truth about their multi-faceted race or ethnicity. CONCLUSION: The VBAC calculator's inclusion of race and ethnicity helped to automate racism by coding race into institutional practices and care interactions. This resulted in some clinicians discouraging or prohibiting Black and Hispanic patients from attempting a VBAC. SIGNIFICANCE: To date, no empiric study has examined whether the VBAC calculator produced inequities in access to VBAC services and reproduced racism in care. The VBAC calculator resulted in fewer VBAC attempts among racially minoritized patients, denying them the opportunity to undergo labor and a vaginal birthing experience.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.011 | 0.064 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.002 | 0.002 |
| Scholarly communication | 0.002 | 0.002 |
| Open science | 0.001 | 0.002 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".